Shoulder Injuries:
A Functional PerspectiveThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: ACA News 2013 (Aug): 34–35
By Gina ShawWhen George Petruska, DC, owner of the Chiropractic & Rehabilitation Center in Pennsburg, Pa., attended an advanced training program for doctors of chiropractic, physical therapists and personal trainers at a large rehabilitation facility in New Jersey recently, he tried out a theory.
“I asked the participants to do two functional tests: the Functional Movement Screen (FMS) and Selective Functional Movement Assessment (SFMA),” he says. These tests assess fundamental patterns of movement and identify dysfunctional movement patterns, pointing to hidden areas of injury.
FMS, for example, is scored on a scale from 3 (no compensation or pain) down to zero—unable to perform the movement without pain. “Every physical therapist there scored a 3 on the shoulder part of the FMS,” says Dr. Petruska. “But every DC in the room had a problem with internal rotation.”
Why is that? “We adjust! It hampers your ability to perform internal rotation without compensation or pain. Mine is terrible,” Dr. Petruska says. For example, he adds, all of the physical therapists were able to reach behind their back and touch fairly high up along the spine, between the T4 and T6 vertebrae. DCs struggled to touch T10.
What does all of this have to do with the shoulder and rotator cuff injuries? It points to a limitation of the standard orthopedic testing that is often used to identify such injuries.
“In my practice, I’ve had athletes come in, or people who are, say, construction workers, union carpenters, pipefitters or electricians. Their physicians have told them that their shoulder pain is bursitis or tendinitis,” Dr. Petruska says. The true extent of the shoulder injury is masked by the compensation of ancillary muscles, and doesn’t appear on standard orthopedic testing. “If you rely on these alone, you could miss a rotator cuff tear.”
Rotator Cuff Injuries
The rotator cuff, as all doctors of chiropractic know, is actually composed of four separate muscles: the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Most of the approximately 2 million people who seek care for rotator cuff injuries in the United States every year have injured the supraspinatus, but the involvement of at least one of the other muscles is more common than was previously thought, says Dale Huntington, DC, owner of the Huntington Chiropractic Clinic in Springdale, Ark. “We used to think these tears were just in the super-spinatus 90 percent of the time. Now we’re realizing that, in the converging of these tendons, the infraspinatus is often being torn as well.”
And many people, especially athletes, may be walking around with small rotator cuff tears (a full tear usually requires surgery) without realizing it, because they’ve become so used to working or playing through the pain. “If you’re the DC for your local high school or college team, or even a pro team, you want to screen all of your athletes with functional movement screening to determine if there’s anything wrong with their shoulders,” says Dr. Petruska.
In addition to the FMS and the SFMA, Dr. Petruska relies on what noted sports chiropractor Craig Liebenson, DC, director of L.A. Sports and Spine, calls “the Magnificent 7”—a series of functional tests that appear in his popular Rehabilitation of the Spine manual.
“With functional testing, you can isolate the underlying problem, whether it’s regional interdependence, muscle imbalance, red light reflex, upper crossed syndrome—because there’s a reason why that person got injured to begin with,” Dr. Petruska says. “The rotator cuff didn’t just magically tear. A series of events led to that happening. Once you’ve identified that, from there you can design a functional treatment plan to handle the situation.”
Some patients, as Dr. Petruska points out, may not even realize that they’ve injured their shoulder. But many others will walk into your office complaining of a pain that could be bursitis or tendinitis, could be impingement syndrome (a precursor to a rotator cuff tear), or could be a microscopic or more severe tear.
With these patients, functional testing goes hand in hand with the diagnostic exam and patient history. Key questions to ask your patient include:
How long have you had this pain?
Was there a specific event that precipitated it? Were you doing something around then that you don’t usually do?
Are you taking any medications (i.e., some might cause weakness in the muscle)?
Have you had any injections into the site previously?
Have you injured the site previously? If so, what sort of therapy did you seek? Was it successful?
Have you had any prior imaging studies?
“You have to be very specific,” says Dr. Huntington. “Sometimes patients aren’t very forthcoming, and if you aren’t well versed in the examination process for the rotator cuff, you won’t get very far.”
If the exam and functional testing point to a rotator- cuff tear, imaging may be needed to determine the degree of injury.
When doing an X-ray, the two most important views to get for a shoulder injury are the neutral arm view and the “baby arm,” or abduction/external rotation shoulder view, as well as internal rotation, says Dr. Huntington.
“For these soft-tissue injuries, we are going more and more to diagnostic ultrasounds,” says prominent sports chiropractor, Thomas Hyde, DC, who recently retired from active practice in Asheville, N.C. “They’re noninvasive and readily available in most areas, and can give you a great deal of information about nonbony injuries.”
First-degree, or “microscopic,” tears and second-degree tears (a nebulous category defined as “greater than microscopic”) can usually be rehabilitated with conservative management.
Rehabilitation
Third-degree tears are thought to virtually always require surgery, but Dr. Hyde says that is not necessarily the case. “However, if you have an elite athlete, of course that athlete is probably going to be evaluated by an orthopedic surgeon,” he says. “I had a 78-year-old man who was still an excellent tennis player with a third-degree tear of his supraspinatus. I gave him the option of going to an orthopedic surgeon or doing rehab with me, explaining that he might lose mobility and need other muscles to compensate. That’s what we did; he couldn’t do an overhand serve, but he served underhand and went back to playing great tennis without surgery.”
That might be controversial, but Dr. Hyde points out that surgery can pose risks for a 78-year-old, no matter how healthy. Some, like his patient, may see conservative management as preferable to those risks. “You just have to be careful that you understand what you’re doing from a rehab point of view, so you don’t disrupt the surrounding structures.”
To rehabilitate a rotator cuff tear, says Dr. Petruska, it’s important to start with the patient’s mobility. “You cannot build stability over poor mobility. You’ll fail every time. It’s a common mistake a lot of practitioners make, and then their treatment fails and they wonder why. The patient comes back with a reinjury or more pain, it’s determined that ‘conservative care failed,’ and now it’s necessary to do surgery.”
To avoid that outcome, Dr. Petruska recommends adhering faithfully to a careful rehabilitation pattern:
Perform initial passive care. Options during this stage include manipulation, Graston, neuromobilization, flexion/distraction, laser, anodyne therapy and many others.
Fix the mobility. Physical therapist Gray Cook and sports medicine expert Lee Burton, PhD, developers of Functional Movement Systems, offer a series of simple exercises to improve shoulder mobility on their website, functionalmovement.com.
Strengthen the inner core, then the outer core. Standard tools for this stage include thera pads, rocker boards and Bosu balls.
Work next on postural stabilizers such as the glutes and knees. “Always look for imbalances,” Dr. Petruska says.
Next, work on endurance, and assess the patient’s overall condition with tests such as the Harvard Step Test or an EKG. “Faulty breathing patterns can lead to functional deficits,” says Dr. Petruska.
For deconditioned patients, work them up to a higher level through high-intensity interval training. Dr. Petruska suggests a regimen such as 7 minutes on the treadmill, 7 minutes on the elliptical, 7 minutes on the recumbent bike and 7 minutes on the upright stationary bike. “You want to rotate and cross train.”
The next step involves functional integrated training (FIT). In this stage, the patient should be challenged using options such as Otis rings on a gym ball, Bodyblade on a rocker board or playing catch with medicine balls on a Bosu ball.
Now, finally you are ready to strength train. “It’s the very last thing you do, and honestly it’s only about 5 percent of the importance. Whether you’re using kettle bells, therabands, free weights, whatever, that’s less important than going through the right steps of rehab progression,” Dr. Petruska advises.
“Throughout this process, you want to turn short-term corrections into long-term gains,” he says. “You’re trying to make certain actions automatic, and you never want to train a bad or deficient motor pattern. If your patient is doing an exercise incorrectly, stop and let him or her rest.”
Although the rehab progression should be consistent, things such as specific exercises and time spent in each phase will differ patient by patient. “You have to consider the individual in front of you: age, lifestyle, overall condition, symptoms and the severity of the injury. It’s not cookie cutter,” says Dr. Hyde. “And these things take time. Rotator cuff injuries are not a quick adjustment and out the door.”
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